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Event Notification Report for October 29, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/28/2014 - 10/29/2014

** EVENT NUMBERS **


49967 50552 50554 50555

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Part 21 Event Number: 49967
Rep Org: C&D TECHNOLOGIES INC
Licensee: C&D TECHNOLOGIES INC
Region: 1
City: BLUE BELL State: PA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: CHRISTIAN RHEAULT
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/28/2014
Notification Time: 13:02 [ET]
Event Date: 02/14/2012
Event Time: [EDT]
Last Update Date: 10/28/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
MEL GRAY (R1DO)
MARVIN SYKES (R2DO)
BILLY DICKSON (R3DO)
NRR PART 21 GROUP (EMAI)

Event Text

INTERIM PART 21 REPORT - MISALIGNED SEPARATORS IN LCR-25 STANDBY BATTERIES

The following is the summary portion of the report submitted by fax:

"Subject Interim Report - Inability to Complete 10CFR Part 21 Evaluation Regarding Misaligned Separators in LCR-25 Standby Batteries

"The purpose of this letter is to provide the NRC a report in general conformity to the requirements of 10CFR Part 21.21 (a)(2). On February 14, 2012 C&D Technologies, Inc. ('C&D') was informed by Entergy Operations that an LCR-25 battery installed at the Palisades Nuclear Power Plant had shown signs of misaligned separators (also known as shifted separators) of between 1/8 to1/4 [inch]. This was identified by the Palisades plant on or about November 4, 2011. On January 16, 2012, three additional cells were identified as experiencing separator misalignment.

"C&D requested that Palisades return the affected batteries for evaluation of this anomaly and issued a Return Material Authorization for that purpose. But since voltage readings were acceptable for all units involved, Palisades determined that an operability issue did not exist and opted to keep the batteries in service until their refuel outage scheduled for Fall, 2013. C&D inadvertently closed the internal corrective action without providing an Interim Report as required by 10CFR, Part 21.

"C&D has not performed a root cause technical evaluation to determine if there is any defect in the component or manufacturing process or whether the reported condition may have been due to user abuse of product, improper maintenance or other negligence or error.

"Thus, C&D is submitting this interim report to the NRC and notifying C&D's customers that use C&D LCR-25 batteries of this interim report, and is initiating an action plan to evaluate the reported potential defect and determine whether it could pose a substantial safety hazard for any U.S. licensee using such batteries.

"If you have any questions or wish to discuss this matter or this report, please contact:

Robert Malley
VP Quality and Process Engineering
bmalley@cdtechno.com
(215) 619-7830"

The sites affected are:
Palisades - 65 x LCR-25 NUC Batteries and,
Crystal River - 4 x LCR-25 NUC Batteries

* * * UPDATE FROM LARRY CARSON TO JOHN SHOEMAKER AT 1122 EDT ON 09/16/14 * * *

The following was excerpted from the final report received from C&D Technologies, Inc. via facsimile:

"Conclusion: The conclusion drawn from the return and analysis is that the misaligned separator was present from the time of assembly in the C&D facility through installation and initial operation.

"Recommendations: C&D recommends that operators of nuclear batteries perform an inspection of their batteries to detect misaligned separators. Inspection may be performed visually, and with the aid of mirrors as necessary.

"Corrective Actions: C&D has enhanced both in process and final battery inspection processes to detect and eliminate misaligned separators from shipment. C&D is also preparing an enhanced incoming inspection work form for nuclear battery operators that will better enable the operators to detect and segregate batteries with misaligned separators from use.

"Further Reporting: No further reporting is anticipated.

"C&D Contacts: Further information on this issue can be obtained from:

"Larry Carson- Nuclear Product Manager
Office Phone 215-775-1314
Email: lcarson@cdtechno.com

"Robert Malley-VP Quality and Process Engineering
Office Phone 215-619-7830
Email bmalley@cdtechno.com"

Notified R1DO (Lilliendahl), R2DO (Sykes), R3DO (Dickenson), and NRR Part 21 Group via email.

* * * UPDATE PROVIDED FROM ROBERT MALLEY TO JEFF ROTTON AT 1505 EDT ON 10/28/2014 * * *

The following information was excerpted from the revised final report submitted by email:

This update (dated 9/22/2014 and provided to NRC on 10/28/2014) is Revision 1 to Final Report from C&D Technologies originally submitted on 9/16/2014.

"An interim report was submitted 3/27/14 while the product was being returned for analysis.

"C&D has performed an analysis of the returned product, and is submitting this report to the NRC and notifying affected C&D customers to the possibility of separator misalignment in LCR, KCR, and LCY products [versus original report affecting LCR products only].

"U.S. Licensees using batteries possibly containing the potential defect are being notified of the filing of this final report with recommendations that they examine their batteries for any signs of similar problems.

"If you have any questions or wish to discuss this matter or this report, please contact:

"Robert Malley, VP Quality and Process Engineering, bmalley@cdtechno.com, (215) 619-7830."

List of affected plants:

NRC Region 1: Nine Mile Point, Millstone, Indian Point, Vermont Yankee, Limerick, Three Mile Island, Beaver Valley, Susquehanna, Salem, Hope Creek, Crystal River

NRC Region 2: Oconee, St. Lucie, Harris, Robinson, Summer, Farley, Hatch, Vogtle, Browns Ferry, Sequoyah, Watts Bar

NRC Region 3: Kewaunee, Fermi, Palisades, Braidwood, Byron, Clinton, LaSalle, Perry, Cook, Duane Arnold, Point Beach, Monticello, Prairie Island

NRC Region 4: Arkansas Nuclear One, Grand Gulf, Waterford, Cooper, Fort Calhoun, Diablo Canyon

Foreign: Bruce, Laguna Verde, Point Lepreau, Krsko, Darlington, Pickering, Chin Shan, Kuosheng, Maanshan, Lungmen

Other: Knoll Atomic Power Laboratory

Notified R1DO (Bickett), R2DO (Blamey), R3DO (Lipa), R4DO (Whitten) and NRR Part 21 Group via email.


* * * UPDATE PROVIDED BY ROBERT MALLEY TO JEFF ROTTON AT 1143 EDT ON 10/28/2014 * * *

The following was excerpted from the final report update received by fax:

"The purpose of this letter is to update a report provided to the NRC on 09/22/14 regarding misaligned separators in Class 1 E battery products. We are revising Section II for the models of the product affected, and Section VIII for the advice provided for customers. These revisions are provided below:
"(ii) Identification of the facility, the activity, or the basic component supplied for such facility or such activity within the United States which fails to comply or contains a defect.

"The products affected include LCUN and LCU model lines in addition to the previously reported LCR, KCR, and LCY products. [This did not add to the list of facilities affected]

"(viii) Any advice related to the defect or failure to comply about the facility, activity, or basic component that has been, is being, or will be given to purchasers or licensees.

"Based on experience gained through site visits and review of products that completed product life C&D is changing the criteria for inclusion in the scope of this Part 21 report. The change increases the allowable separator misalignment.

"If you have any questions or wish to discuss this matter or this report, please contact:

"Robert Malley, VP Quality and Process Engineering, bmalley@cdtechno.com, (215) 619-7830."

Notified R1DO (Bickett), R2DO (Blamey), R3DO (Lipa), R4DO (Whitten) and NRR Part 21 Group via email.

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Agreement State Event Number: 50552
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: DESERT NDT LLC
Region: 4
City: PHARR State: TX
County:
License #: 06462
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 10/20/2014
Notification Time: 16:03 [ET]
Event Date: 10/20/2014
Event Time: [CDT]
Last Update Date: 10/20/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WAYNE WALKER (R4DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE RETRACTION FAILURE

The following information was received via facsimile:

"On October 20, 2014, the Agency [Texas Department of State Health Services] received notice that there had been a radiography source retraction failure at a temporary field site. A pipe had fallen from a stand onto the guide tube, causing a crimp. The source was retrieved by squeezing the crimp with pliers several times, allowing retraction. The individual performing the retrieval received 198 mR according to a pocket dosimeter. The camera was an INC IR-100 (sn 6832) with an Ir-192 source at 44 Ci (sn W644 ). Additional information will be supplied as it is received in accordance with SA-300."

This event occurred at a field site in Encinal, Texas.

Texas Incident #: I-9245

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Agreement State Event Number: 50554
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: OREGON HEALTH AND SCIENCE UNIVERSITY
Region: 4
City: PORTLAND State: OR
County:
License #: 90013
Agreement: Y
Docket:
NRC Notified By: TODD CARPENTER
HQ OPS Officer: RICHARD SMITH
Notification Date: 10/21/2014
Notification Time: 11:32 [ET]
Event Date: 10/17/2014
Event Time: [PDT]
Last Update Date: 10/21/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WAYNE WALKER (R4DO)
FSME EVENTS RESOURCE (EMAI)
JACK GUTTMANN (NMSS)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

The following information was received via email:

"This is the initial notification that, on Friday, October 17th in Nuclear Medicine at OHSU [Oregon Health and Science University], a patient who was supposed to receive 25 mCi Tc-99m Sestamibi for a parathyroid scan was injected with 25.9 mCi of Tc-99m MDP, a bone scanning agent.

"The patient was notified, as was the referring physician. The patient was accompanied to meet with the referring physician. At this time, the exam will not be rescheduled. Investigation with the injecting technologist still in progress, and a letter will be sent to the patient.

"Radiation protection services will follow up with additional information."

Oregon Incident Number: 14-0040

A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

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Agreement State Event Number: 50555
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: EASTMAN CHEMICAL COMPANY
Region: 1
City: KINGSPORT State: TN
County:
License #: R-82007-H18
Agreement: Y
Docket:
NRC Notified By: RUBEN CROSSLIN
HQ OPS Officer: RICHARD SMITH
Notification Date: 10/21/2014
Notification Time: 12:12 [ET]
Event Date: 10/17/2014
Event Time: [EDT]
Last Update Date: 10/21/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAN SCHROEDER (R1DO)
JACK GUTTMANN (NMSS)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - PROCESS GAUGE STUCK SHUTTER

The following information was received via email:

"The licensee called to report a radioactive material gauge with stuck shutter in the open position on a continuous process Vega Model SHLG1, SN 63133 gauge with a 300 milliCurie Cs-137 source. There are no adverse exposure or other problems. Routine operations will continue. The gauge manufacturer will be contacted."

TN Report ID Number: TN-14-197

Page Last Reviewed/Updated Wednesday, October 29, 2014
Wednesday, October 29, 2014